Cath Lab Essentials:

Basic Hemodynamics for the

Cath Lab and ICU

Ailin Barseghian El-Farra, MD, FACC

Assistant Professor, Interventional Cardiology
University of California, Irvine
Department of Cardiology
 Right Heart
Catheterization
By Don Ramey Logan - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=38538349
 INDICATIONS
• Cause of shock
• Pulmonary hypertension
• Fluid management and hemodynamic
monitoring
• Guidance for pericardial tamponade
• Constrictive versus restrictive
cardiomyopathy
• Diagnosis of left to right shunt
 CONTRAINDICATIONS
• ABSOLUTE
contraindications:
– None
• CAUTION:
– Pulmonary
hypertension
– Elderly
– Left bundle
branch block
EQUIPMENT
 PULMONARY ARTERY CATHETER
EXTRA PORT DISTAL PORT

PROXIMAL PORT

THERMISTOR

BALLOON
TECHNIQUE
 A Systematic Approach to
Hemodynamic Interpretation
1. Establish the zero level and balance transducer.
2. Confirm the scale of the recording.
-40 mmHg for RHC, 200 mmHg for LHC
3. Collect hemodynamics in a systematic method using
established protocols.
4. Critically assess the pressure waveforms for proper
fidelity.
5. Carefully time pressure events with the ECG.
6. Review the tracings for common artifacts
 Components of a Right Heart
Catheterization
1.Right atrium Pulm HTN: mean
– Mean (1-5 mmHg) PA pressure > 25mmHg
2.Right ventricle PCWP < 15mmhg
– Phasic (25/5 mmHg)
3.Pulmonary capillary wedge
– Mean (7-12 mmHg)
4.Pulmonary artery
– Phasic and mean (25/10 mmHg; mean 10-20
mmHg)
 Precautions
• Always record pressures at end-expiration
• During inspiration, pressures will be lower
due to decrease in intrathoracic pressure
• Always zero and reference the system
“SAT RUN” RA to PA STEP UP
highest or average
SVC values ≥ 5% LUNGS
SVC to RA
STEP UP
If highest RIGHT
values are ATRIUM
used, at RA to RV STEP UP
least ≥ 11% highest values are
If average of used, at least ≥
multiple 10%
samples, IVC If average of
then ≥ 7% multiple samples,
then ≥ 5%
(for L-> R shunt)
1
SIMULTANEOUS RIGHT- and LEFT- HEART CATHETERIZATION
1. Pulmonary artery (PA) catheter to pulmonary artery
2. Measure cardiac output by measuring oxygen saturation in PA
and AO blood samples to determine Fick output or by
thermodilution (x3); screen for shunt.
3. Record aortic pressures with AO catheter. Cross the AV into the
ventricle -> Wedge the PA catheter -> Measure simultaneous LV-
PCWP (mitral valve assessment).
4. Pull back from PCWP to PA.
5. Pull back from PA to right ventricle (RV) (to screen for pulmonic
stenosis) and record RV.
6. Record simultaneous LV-RV (constriction vs restriction).
7. Pull back from RV to right atrium (RA) (to screen for tricuspid
stenosis) and record RA
8. Pull back from LV to AO (to screen for aortic stenosis).
CARDIAC CYCLE
 PHASES
1: Atrial Contraction

2: Isovolumic Contraction
(TV/MV closure to PV/AV opening)

3: Rapid Ejection

4: Reduced Ejection
(PV/AV opening to PV/AV closure)

5: Isovolumic Relaxation
(PV/AV closure to TV/MV opening)

6: Rapid Ventricular Filling

7: Reduced Ventricular Filling

(TV/MV opening to TV/MV closure)
PRESSURE WAVE INTERPRETATION
LEFT HEART CATHETERIZATION
PITFALLS
ARTIFACTS
CARDIAC OUTPUT
 Cardiac Output

• Thermodilution
• Fick Method
Thermodilution
• Bolus injection of
saline into the
proximal port
• Change in
temperature is
measured by
thermistor in the
distal portion of
the catheter
 Fick Principle
• Described in 1870
• Assumes rate of O2 consumption is a function of rate of
blood flow times the rate of O2 pick up by the RBC

Oxygen consumption
1. Direct Fick:
-Directly measured
2. Indirect Fick:
--3 ml O2/kg

X 10
 Limitations
Thermodilution
• Not accurate in tricuspid
regurgitation
• Overestimated cardiac
output at low output
states
Fick
• Oxygen consumption is
often estimated by body
weight (indirect method)
rather than measured
directly
• Large errors possible with
small differences in
saturations and hemoglobin.
• Measurements on room air
THANK YOU
 Normal Pressures
Site Normal Value Mean Saturation
(mmHg) Pressure
(mmHg)
Right Atrium 0-5 75%
(or CVP)
Right Ventricle 25/5 75%

Pulmonary 25/10 10-20 75%

Artery
PCWP 7-12 95-100%
LV 120/10 95-100%
Aorta 120/80 95-100%
 Normal Values
Site Value
Sv02 0.60-0.75
Stroke Volume 60-100 ml/beat
Stroke Index 33-47 ml/beat/m2
Cardiac Output 4-8 L/min
Cardiac Index 2.5-4.0 L/min/m2

SVR 800-1200 dynes sec/-cm5

PVR <250 dynes sec/-cm5

MAP 70-110 mmHg

 References
• Bangalore and Bhatt. Right heart catheterization,
coronary angiography and percutaneous
coronary intervention. Circulation, 2011; 124:
e428-e433.
• Kern, Morton J. The Cardiac Catheterization
Handbook. Philadelphia, PA: Saunders Elsevier,
2011. Print.
• Ragosta, Michael. Textbook of Clinical
Hemodynamics. Philadelphia, PA:
Saunders/Elsevier, 2008. Print.